Prevalence of wasting and associated factors among children aged 2–5 years, southern Ethiopia: a community-based cross-sectional study

Background Wasting (acute malnutrition) is the most serious form of malnutrition for children in the near term. Malnutrition has a variety of causes, all of which are interconnected and hierarchically related. The purpose of this study was to assess the prevalence of wasting and its associated determinants among children under the age of five in the Wonago district, Gedeo zone, southern Ethiopia. Methods Community based cross-sectional study was conducted from October 1 to 30, 2021 using a systematic random sampling technique. Data were entered using Epidata manager and STATA v.20 software was used for analysis. Descriptive statistics were reported to describe the study population. To identify associated factors of wasting, bivariate and multivariate logistic regression analysis were fitted. Variables having p-value < 0.05 were declared statistically significant predictors of wasting. Results A total of 390 respondents participated with a response rate of 92.6%. The prevalence of wasting among children aged 2–5 years in Wonago district was 36.4% (95% CI: 31.76–41.32). Moderate household food insecurity (AOR = 0.35, 95%CI: 0.14–0.83), history of recurrent illness (AOR = 0.15, 95%CI: 0.26–0.84), and duration of breastfeeding greater than 2 years (AOR = 0.15, 95%CI: 0.26–0.84) were significantly associated with wasting. Conclusion Almost one-third of the children were wasted. Household food insecurity, breastfeeding, and recurrent illness were significantly associated with wasting among children aged 24–59 months. It is recommended that interventions be designed with food security, disease prevention, and breastfeeding awareness in mind and put the spotlight on food and nutrition policy to insure children’s nutritional status. Supplementary Information The online version contains supplementary material available at 10.1186/s40795-022-00657-x.


Background
Children's nutritional status is a significant measure of a household's living standard and a factor of child survival, as well as a powerful reflection of a country's growth [1]. Malnutrition is a condition in which an individual's physical function is damaged to the degree that she or he is unable to sustain appropriate body performance processes such as growth, pregnancy, lactation, physical work, and illness resistance and recovery [2][3][4].
The World Health Organization (WHO) recommends child malnutrition as one of the health indicators for health equity [5]. Stunting, wasting, and underweight are frequent anthropometric measures used to assess *Correspondence: helab2005@gmail.com 1 Human nutrition department, School of Public Health, Dilla University, Dilla, Ethiopia Full list of author information is available at the end of the article malnutrition in children under the age of five. Underweight (low weight-for-age) represents both low heightfor-age and low weight-for-age, and so chronic and acute malnutrition exposures [6]. In the short term, wasting (acute malnutrition) is the most dangerous type of malnutrition for children. Also known as weight for height with a z-score less than minus two standard deviations from the median weight for height in the standard reference population [7,8].
Under the age of five is a critical developmental period because it represents the transition from childhood to adolescence, spanning the ages of 0-59 months [9].
In developing countries, malnutrition is still a problem for public health. In particular, among young children under the age of five, malnutrition in various forms, such as acute malnutrition or wasting, stunting, and underweight, is still widespread. People all over the world are impacted by it. Currently, it is held responsible for 2.3 million children's deaths, or more than 41% of all fatalities among children under the age of five in developing countries [10].
Wasting still affects 50.5 million children under the age of five globally, with 17 million seriously wasted. The highest prevalence of undernutrition in the world is estimated to affect 264.2 million people in sub-Saharan Africa, or 24.1% of the population, in 2020 [11]. Ethiopia has the highest rate of malnutrition among children under the age of 5 years among Sub-Saharan and East African countries, with 9 and 8.7% of wasted under-fives. It is also one of the leading causes of disease and death among children under the age of five in the country [12].
The causes of malnutrition are numerous and multifaceted which causes are intertwined with each other and are hierarchically related. Poor food and sickness are the immediate determinants which are caused by a number of underlying factors, including household food security, maternal/child care practices, access to health care, and a healthy environment. The basic socio-economic and political situations have an impact on these underlying factors [2]. Diseases with an environmental component, such as those spread by insect or protozoan vectors, or those induced by a micronutrient-deficient environment, plainly impact nutritional health [7].
Despite the efforts of the nongovernmental and government organizations to improve infant and young child feeding (IYCF), wasting among children 2-5 years of age remains a concern in Ethiopia. Nutritional problems have an impact in Ethiopia by affecting the majority of children with severe wasting that accounts one out of every ten children [13].. According to a study conducted in Gobu Soya woreda east Wollega, 12.5% of preschool children are wasted. Family income, family size, and family education were all found to be strongly linked with acute malnutrition among the socioeconomic variables studied [14]. According to the EDHS 2016 data, 9.7% of children are wasted, 28.7% are underweight, and 44.4% are stunted, with considerable regional variations [6]. According to the Health and Health Related Indicators (HHRI) 2014 report, sever acute malnutrition was the fifth greatest cause of death in Ethiopia, accounting for 6.9% of all deaths among children under the age of five [15].
However, there has been a limited study done in Wonago district that demonstrates the prevalence of wasting among children under the age of two to 5 years. Therefore, this study aimed to assess the prevalence of wasting and associated factors among children aged 2-5 years in Wonago district, Gedeo zone, south Ethiopia.

Study area, period and design
A community-based cross-sectional study was conducted in Wonago town, Gedeo zone, South Nation Nationality and People Region (SNNPR), Ethiopia from October 1 to October 30, 2021. The numbers of population in Wonago town is around 156,481. Wonago is located 102, 13, and 377 kms from the zonal, regional and national capitals Hawassa, Dilla, and Addis Ababa, respectively. is bounded by southwest by Yirgachefe District, northwest by the Oromia region, northeast by Dilla Zuriya District, and southeast by Bule District. The town has three Kebeles in which 1737 children aged 2-5 years is found.

Source population
All children aged 2-5 years living in Wonago district.

Study population
Selected children aged 2-5 years paired with their mother/care givers living in Wonago district.
Study Unit. Selected children aged 2-5 years paired with their mother/care givers living in Wonago district and participated in actual response during data collection period. Eligibility All 2-5 children paired with their mother/ care givers living in Wonago district.

Sampling technique and procedure Sample size determination
The sample size was calculated using single population proportion formula by considering the following assumptions: p = 0.476 proportion of wasting in Bulle Hora town with the level of confidence = 95%, level of significance = 5% and margin of error (d) =5%. Therefore, the final total sample size including the non-response rate was 421.

Sampling procedure
A systematic random sampling technique was used. Based on the proportional allocation formula 421 study participants were distributed to the three kebele of wonago town and the kth value was calculated (Kth = 4) (Fig. 1). The first house hold with 2-5 years child in each kebeles was selected randomly from 1 to 5 households by lottery method then the rest was selected every respected 4 household until the total sample size was achieved.

Operational definitions
• Wasted:-A child weight for height z score < −2sd [16] • Not wasted: A child weight for height z score= > −2sd [16] • Caregiver: is a mother, father, any family member or paid person that knows about the child in detail and help the child with feeding, dressing, undressing, and with hygiene. • Food-insecurity: Exists when all people, at all times, lack secure access to sufficient amounts of safe and nutritious food that meets their dietary needs and food preferences for an active and healthy life [17].
• Mildly food insecure (access) household Worries about not having enough food sometimes or often and/or is unable to eat preferred foods [17]. • Moderately food insecure household Sacrifices quality more frequently, by eating a monotonous diet or undesirable foods sometimes or often [17]. • A highly food insecure household Experience forced cutting back on meal size or number of meals often, and/or experiences any of the three most severe conditions [17]. Data Collection Procedures and data quality control

Data collection tool and procedure
A semi-structured interview administered questionnaire, which includes all the relevant information to meet the objectives of the study was used to collect the participants' Socio-economic factors (child age, family size, income, maternal/ paternal education, Household food insecurity), recurrent illness, Child caring practice (feeding, immunization, Dietary diversity), Maternal characteristics: (age of mother, number of children, ANC visit, age at first pregnancy), environmental health conditions, and dietary diversity practice. The tool was adapted Fig. 1 Sampling procedure of the study from the world health organization instrument for stepwise surveillance of (WHO steps) child malnutrition. In accordance with the steps manual, a few additional questions were added to supplement the questionnaire and to reflect the local context of Ethiopia. It was first written in English, translated into Amharic then to Gede'offa (local language), and was translated back into English by professionals who speak both languages for keeping consistency. Lastly, a survey was conducted with the help of health extension professionals checking intra and interprofessional reliability following the selection of eligible households.

Data quality control
Data was gathered by 15 data collectors who had been trained. Supervisors examined the obtained data on a daily basis for completeness and consistency. Those who can take anthropometric measurements of a child gathered the data. Before measuring, the child's shoes, braids, and hair clips were removed to reduce measurement mistakes. For height and weight measurements, a stadiometer and a digital weighing machine were utilized. The child was in a standing position throughout the anthropometric measurements. With their feet together and flat on the ground, their heels pressed against the stadiometer's back plate, their legs straight, buttocks against the backboard, scapula against the backboard, and arms at their sides. Body weight was measured to the nearest 0.1 kg using a stadiometer. The 'Technical Error of the Measurements' was calculated by estimating the average difference between the expert's measurements and those of the trained data collectors, as well as the difference between the data collectors' first and second measurements (TEM). The relative TEMs for inter and intra examiners relative values for height and weight were greater than 0.95, the suggested cutoff, indicating that the measurements in the study were highly accurate. Before the actual data collection took place, pretest was done on the sample of 5% of the sample size, which was in adjacent Woreda to ensure the validity and reliability of methodology and survey tools. Based on the findings of the pretest, the tool was modified. After checking for completeness, the collected data was edited to exclude errors, re-organized, coded and entered into epidata version 4.6 for double data entry verification (to identify data consistency), then was exported to STATA version 20 for windows for cleaning and statistical analysis.

Data processing and analysis
Epidata version 4.6 was used to enter the data. It was examined for completeness, consistency, and coding using STATA version 20 before any statistical analysis. The WHO Antero plus 2021 version 3.2 software was used to convert anthropometric data into z-scores for the indices stunting HAZ (height for age z-score), underweight WAZ (weight for age z-score), and wasting WHZ (weight for height z-score), and then exported to STATA version 20 for further analysis.
STATA was used to describe the study population using descriptive statistics such as frequency distribution, mean, and proportion. The presence of connections between the various independent predictors and the dependent variable was investigated using bivariate and multivariable logistic regressions. In the bivariate analysis, variables having a p-value of less than 0.25 [18] were put into multivariable logistic regression. Variables with a p-value of less than 0.05 in the multivariate analysis were declared statistically linked with wasting in children aged 2 to 5. Finally, conclusions were drawn based on the findings.

Ethical consideration
The study was conducted after ethical clearance was obtained from the DU review board. Oral consent was gained from the study participants before they were enrolled in the study and anybody involved in this study was informed that she or he has full right to leave the study. The information collected from the respondents were used only for the study purpose.

Maternal characteristics
Mothers who had ANC follow up was 304 (78%) and the number of mothers who utilised family planning was 328 (84.1%), whereas 62 (15.9%) did not utilize family planning. 181 (46.41%) mothers wash their hands after using the restroom, 152 (39.0%) wash their hands before preparing food, 46 (11.79%) wash their hands before serving, and 11 (2.8%) people wash their hands after washing or caring for a baby (Table 4).

Environmental conditions
River water was used as a source of water by 29 (7.44%) of the respondents. Traditional private pit latrines with wooden slab was the commonest type 181(46.41%).  (Table 5).

Factors associated with wasting
First, bi-variate analysis was done and variables with p-value of less than 0.25 were included for multivariate analysis. In the multivariate analysis variable having p value of < 0.05 were declared statistically significant predictors of wasting. Household food insecurity, recurrent illness, and duration of breast feeding were significantly associated with wasting among children aged 2-5 years. Children in a households with moderate food insecurity were 65% (AOR = 0.35, 95%CI: 0.14-0.83 P value of 0.03) times lower risk of having wasting compared to Children in a  households with highly food insecure households. Those children who had no history of recurrent illness were 85% (AOR = 0.15, 95%CI: 0.26-0.84, P value of 0.02) less likely to develop wasting when they are compared to children who had history of recurrent illness. Duration of breast feeding for more than 2 years was found to be 55% (AOR = 0.15, 95%CI: 0.26-0.84 p value of 0.017) protective from wasted when compared with breastfeeding less than 2 years (Table 6).

Discussion
This study was primarily intended to estimate the prevalence of wasting (acute malnutrition) and identify the potential predictors of wasting among children aged 2 to 5 years. A total of 390 children were recruited from three kebeles. Wasting is still prevalent in many impoverished nations, including Ethiopia. According to this study, acute malnutrition is an issue in the Wonago district, and it affects children aged 2 to 5 years. Our study revealed that the prevalence of wasting was 36.4% (95% CI: 31.23-40.76), which is higher when compared to a study conducted in Mongolia, nearly one out of every five children (22%) suffers from wasting [1]. This could be related to differences in study area, socioeconomic features, health service delivery, and study location. The percentage of wasted children in the current study was also higher than the national level reported by the Ethiopian Demographic and Health Survey (EDHS) 2011, EDHS 2016, and EDHS 2019 [19][20][21]. This holds with regional levels too, which could be attributable to sample size variations.
In comparison to a study performed in three districts of Nepal's hilly region (Lamgung, Tanahu, and Gorkha), our study found an increase of 11% among children under the age of five [22]. This could be attributable to the research area and variation of residents' nutritional status. South Asia has the greatest rate of malnutrition of any region; according to the 2018 global nutrition report, 23% of children are wasted, which is lower than our findings [9].
It is observed to be greater when compared to similar studies conducted in different parts of Ethiopia. In a   community-based cross-sectional study conducted in rural kebeles in Haramaya district, 14.1% were wasted. The high prevalence of wasting status could be ascribed to unregulated drinking water sources, which could contribute to various infections, as well as the data collection period, which runs in October, when most homes are short on food. Despite the positive results and continued efforts to prevent and reduce under-five malnutrition, Ethiopia continues to struggle with undernutrition as a major health issue. In the multilevel analysis, only household food insecurity, recurrent illness, and breastfeeding status were identified as a significant predictors of wasting among children aged 2 to 5 years at p-value of < 0.05. The findings of this study reveal that children from families with a moderate level of food insecurity are less likely to be wasted than children from families with a high level of food insecurity. When compared to families with highly food insecure, families with moderate food insecurity had more opportunities to access multiple food groups, which might be the possible reason [23]. Indeed, seasonal variations in food supply, acute food shortages, changes in socioeconomic policy, and diseases developing at higher levels than expected are all linked to wasting [24][25][26].
Children with recurrent illnesses had a higher risk of wasting in the current study than children who did not have recurrent illness. Supported by the previous study done in Burkina Faso [27]. This could be due to the fact that infection leads the body to lose more energy, predisposing children to wasting. Recurrent acute illnesses are a significant contributor to linear growth retardation [28]. The study also revealed that children who breastfeed for more than 2 years are less likely to develop wasting than children who breastfeed for less than 2 years. This is in line with a study conducted in Kenya, [29] which found that children who had discontinued breastfeeding were likely to be wasted.

Strengths and limitations
Anthropometric data collection training was taken to reduce technical measurement errors. Additionally, the study was done at the community level which increases the generalizability of the study. Besides it strength, this